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Encouraging exercise as treatment for severe or persistent depression

For patients living with severe or persistent depression, it’s important to provide medical intervention. Then, where do lifestyle changes come into play? It will be hard for your patients to find the motivation to incorporate exercise into their management plan while also prioritizing psychological treatment and/or an antidepressant.


As many as 70% of adults with depression do not get full symptom relief with initial antidepressant treatment.1 Around one-third of those meeting criteria for clinical depression have severe disorder, and these patients are less likely to respond and achieve remission even with both psychological treatment and an antidepressant.1 It’s easy to feel that remission is just not realistic for many patients.


Discussing lifestyle changes with patients who have persistent depression is challenging when you’re limited to the duration of a medical check-up. It takes significant time and effort to provide the necessary education, encouragement, and support for patients to implement an exercise regimen. It probably feels like there’s not much you can do to make an impact.


If you are able to support your patients in starting an exercise program, most healthcare professionals concede that it can significantly reduce symptoms of depression. However, the evidence for specific exercise interventions is of poor quality.1,2 Problems with these studies include small sample sizes, diverse exercise regimens and durations, varying control criteria, and unblinded participants and/or assessors.2


By considering what is proven to improve symptoms of severe or persistent depression, you and your team can better strategize how to bring these benefits to your patients.


A 2019 meta-analysis looked at the effects of physical exercise as add-on therapy in patients with chronic brain disorders, including chronic depression.3 Authors described a dose-dependent reduction in depressive symptoms, with added benefit for every additional minute of exercise per week.3


Studies in patients admitted to hospital for mental health treatment have also shown that exercise programs can improve depression when implemented as an adjunct to prescribed medication.4 Positive results were seen for inpatients, including those with complex and severe depression, using exercise programs involving aerobic activity such as running, walking, and cycling, and using aerobic exercise combined with strength training.4


Exercise intensity has also been well-studied as an influencer of depression symptoms. High-intensity interval training reduces symptoms compared to low-intensity exercise sessions, though high-intensity interval training compared to moderate-intensity training has yielded mixed results.4 A 2023 meta-analysis concluded that, although high-intensity exercise may have added benefit for some, working towards moderate-intensity aerobic activity is an approach that patients with any severity of depression can benefit from.5


There is also evidence that supervised or group-based exercise sessions in hospital or community settings lead to larger improvements in depression symptoms compared to patients planning their own exercise regimens.4,5 In short, adding exercise to patients’ management improves depression symptoms in many cases. This is why guidelines recommend exercise for every person with depression, including those taking an antidepressant and/or receiving psychological treatment.1,2,6


There are many ways to help your patients to start exercising. Discussing the types of exercise that have been studied and the potential benefits may be a great place to begin when exploring possibilities with your patients. Focus the conversation on increasing time spent exercising, achieving moderate intensity levels, and possibly joining group activities.


Aim to understand your patients’ interests, activity level, and what usually sparks joy for them in order to find ways to implement recommended exercise. Collaborate with other members of your team to help your patients develop plans that fit into their daily routines, meet their individual needs, and bring them long-lasting benefits. Have information ready about various local programs and useful resources in order to engage patients during short appointments. You can then discuss their progress during their next follow-up appointment.


Even small changes in exercise levels can make a significant impact on depression symptoms, even for patients living with severe and persistent depression. Incorporate some new strategies and advice on increased physical activity for all patients with ongoing depression.

 

HelpGuide.org has resources for patients that explain the benefits of exercise for depression and other mental health conditions and provide encouraging tips for implementing an exercise regimen. Exercise is Medicine, managed by the American College of Sports Medicine, also has patient resources including one called “Being active when you have depression and anxiety” that patients may find useful.

 

References


1. Qaseem A, Owens DK, Etxeandia-Ikobaltzeta I, et al. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians. Ann Intern Med. 2023;176(2):239-253. doi:10.7326/M22-2056

2. VA/DoD Clinical Practice Guideline for the management of major depressive disorder. Department of Veterans Affairs & Department of Defense. Version 4.0, 2022. Available at: https://www.healthquality.va.gov/guidelines/MH/mdd/. Accessed July 4, 2023.

3. Dauwan M, Begemann MJH, Slot MIE, Lee EHM, Scheltens P, Sommer IEC. Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials. J Neurol. 2021;268(4):1222-1246. doi:10.1007/s00415-019-09493-9

4. Martland R, Korman N, Firth J, Stubbs B. The efficacy of exercise interventions for all types of inpatients across mental health settings: A systematic review and meta-analysis of 47 studies. J Sports Sci. 2023;41(3):232-271. doi:10.1080/02640414.2023.2207855

5. Heissel A, Heinen D, Brokmeier LL, et al. Exercise as medicine for depressive symptoms? A systematic review and meta-analysis with meta-regression. Br J Sports Med. Published online February 1, 2023. doi:10.1136/bjsports-2022-106282

6. Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry. 2021;55(1):7-117. doi:10.1177/0004867420979353


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